PAS Flashcards
What is the science view of death? Psychological? Law/regulation?
Science = Make death a medical problem by controlling its causes
Psych = Put death out of sight
Law/regulation = Let people control how they want
What were the assumptions that were wrong with the SUPPORT study?
- Pt can articulate preference
- Preferences are stable
- Parties will make decisions at critical junctions
- Pts and surrogates will step forward and take responsibility for decisions
- Decision-makers incorporate information rationally
What are the three characteristics of clinical decision making at the end of life?
- Medically complex
- Personally demanding
- Evolve over time
True or false: the SUPPORT study concluded that an autonomy based framework is the best means of making decisions at the end of life?
False–fell short of expectations
What is the pattern of function/time for patients with organ failure?
“sawtooth pattern”–intermittent bouts of decreased function, but a general downward trend
What are the beneficence/ nonmaleficence aspects of palliative care?
- Optimize QOL
- Cover the continuum of illness
- Aggressive symptom management
What are the autonomy aspects of palliative care?
Patient and family centered decision making that is supportive
What is the scope of palliative care? (5)
- Physical
- Intellectual
- Emotional
- Social
- Spiritual
What are the 7 goals of care?
- Be cured
- Live longer
- Improve or maintain function / QOL
- Be comfortable
- Achieve life goals
- Family support
- Clarify diagnoses / prognoses
FLACCID
What is the major difference between the paternalistic model, shared decision making model, and the informed model of medical care?
Both the information exchange, deliberation, and ultimate decision are based on patient and doctor decision making, instead of one or ther other
What is the best question to ask regarding end of life care?
“what are your goals of care”? (which of the 7)
What is the best way to ask questions when first meeting patients, or beginning a conversation of end of life care (generally)?
Open-ended ones
When should a discussion about goals be done, relative to treatment?
Before treatment / intervention
Where should cost factor into the decision about treatment?
Not at the bedside–“Hidden in the shadows”
What is the MOA of venlafaxine?
SNRI (Effexor)
What is the use and MOA of rifaximin?
Non-absorbable abx used in the treatment of bowel infections.
interferes with transcription by binding to the β-subunit of bacterial RNA polymerase
What are the factors that should be considered with any treatment decision? (4)
- Goals
- costs
- Treatment burden
- Probability of outcome
What are the 5 steps of the spectrum toward end of life?
- Withhold
- Withdraw
- Intensive palliation
- Palliative sedation
- PAS
What is the opinion of the AAHPM on the moral and legal views of withholding / withdrawing and PAS
- Morally the same and appropriate
- Legally distinct from PAS
What is the difference between DNRs and advanced directives?
- Advance directives are directions for future care
- DNR are orders for now
What is the purpose of advanced directives?
To increase the likelihood that patients’ treatment preferences will be honored when the can no longer speak for themselves
What are the two types of advance directives?
Living will
Durable power of attorney
What is a living will?
Spelled out decisions of one’s own medical preferences
What is durable power of attorney?
Names someone else to make medical choices on behalf of the patient
What are the conditions in which a living will becomes applicable?
Patient is incapacitated and:
-Patient’s condition is terminal
OR
-Permanently unconscious
What is the order of authority of medical decision makers if a pt is incapacitated w/o a living will or DPOA?
- Guardian
- Spouse
- Adult children
- Parents
- Adult sibling
What are the two legal standards that people with the durable power of attorney must abide by?
- In accordance with the desires of the patient
- Is in the best interest of the patient
If a patient’s desires are completely unknown, what guides your decision making?
Act in the best interest of the patient
What is the physician’s conscious clause?
A health care provider is not subject to criminal prosecution, etc for failing to withhold or withdraw health care necessary to keep the patient alive
What is the IPOST?
Order form that is active as soon as it’s signed–specifies the type of care wanted, who makes decisions, and rationale for care.
What are the two signatures that are needed on an IPOST?
Healthcare provider + patient or appointed guardian
True or false: by law, you have to follow IPOST all the time
False
What are the two forms of advanced directives where power may be exercised without the patient being terminally ill or permanently unconscious?
Durable POA
IPOST
What is the intention of the DNR?
Preserve comfort, not to cause or hasten death
What is the difference between palliative and terminal sedation?
Palliative sedation = treating with sedation to control pain, with possibility of death as outcome
Terminal sedation = sedate to kill
What are the two questions that should be asked when withholding/withdrawing?
What is intended?
What causes death
What is the principle of double effect?
To justify foreseen but unintended negative consequences of a good intervention
Fits that paradigm of a side effect
What are the 4 qualifications of the principle of double effect?
The action:
- Is not itself unethical
- Only intends the good effect
- Does not achieve the good effect by means of the bad
- Do for a proportionately serious reasons
What is the definition of PAS?
Medical help is provided to enable a patient to perform an act the is specifically intended to take his or her own lift
What is the the difference between euthanasia and PAS?
Euthanasia is when the physician performs the act that is intended to take the lift of a patient.
True or false: semantics are heavily debated with PAS
True
What is the oath that goes against PAS?
Hippocratic oath
What happen to the disagreement with PAS in drs who have higher numbers of terminally ill patients?
More disagreement with taking care of more terminally ill patients
What was the outcome of the supreme court ruling in 1997 in terms of PAS?
There is no constitutional right to PAS
True or false: nearly all patients who receive medications to commit suicide use them
False–most do not use them
What percent of patient wish for PAS d/t insufferable pain?
25%
Generally, is the power of the Durable POA restricted or unrestricted by clinical situations?
Unrestricted
True or false: IPOSTs can be used for both children and adults
True
True or false: IPOSTS are restricted to those people with terminal illness or permanent unconsciousness
False–not restricted
Which takes precedence in case of conflict: an IPOST, vs a DPOA, living will etc
DPOA or living will will each take precedence over an IPOST
What is the major issue of the principle of double effect in terms of treating pain with morphine?
May prolong the death of patients
What is the motivation for palliative care vs PAS?
- Respect persons with palliative care
- Respect choice with PAS
What is the intention with Palliative care vs PAS?
Palliative care = comfort
PAS = death
What is the outcome of Palliative care vs PAS?
Palliative care = life of death
PAS = death
What is the cause of death with Palliative care vs PAS?
Palliative care = disease
PAS = medication
Should autonomy be the foundation for human dignity?
No (human value should not be equated with the ability to make choices)
